Source: Cell Press
Source: Cell Press
At the time of this writing, there are more than 37 million confirmed cases of Coronavirus Disease 2019 (COVID-19) worldwide. The pandemic has drastically altered daily life and is reshaping society as people navigate previously unimaginable challenges to personal, family, professional, and community safety. Alongside the well-recognized respiratory effects of COVID-19 are neurologic  and neuropsychiatric ones  that have been given less attention in the academic literature and public sphere, and the intersections between the neurologic effects and the neuroethics implications of the pandemic have been scarcely considered.
We also identified commonalities in public health responses and mitigation strategies to these various epidemics/pandemics, including quarantine, isolation of vulnerable populations, and vaccination programs when available [3.,4.,5.]. Notably, face covering was an adjunct, but not a central part, of the public health response in most prior pandemics, as the efficacy had not been proven by large-scale studies. The scale and global impact of COVID-19 is unique, however, with the extent of physical distancing required and the enormous impact on different health systems and economies worldwide.
An effective collective response to COVID-19 relies in large part on a cadre of experts who can make difficult public health decisions based on the best available evidence, including the experience of past pandemics. The operationalization of these decisions, however, relies on the concerted efforts of both the general public and frontline health care workers. This creates an ethical dilemma where public health decisions are largely utilitarian, in that they are made for the greater good, but they may have disproportionately negative effects on the very people who must implement them. In this regard, post-traumatic stress has been well documented after past epidemics [2,6,7]; COVID-19, however, may also bring to bear not only post-, but antecedent neuropsychiatric effects.
As two of the authors (C.F. and J.I.) discussed in the Royal Society of Canada Zero Canada COVID-19 series (https://rsc-src.ca/en/voices/hidden-risks-pre-traumatic-stress), the negative impact from anticipating surges of patients of unknown size and location, and accompanying moral dilemmas, may be as difficult as surviving them. As if this challenge alone was not enough, it exists against a well-documented backdrop of already existing fragilities of mental health among frontline health care workers [8,9]. Recognition, awareness, and attention to this extra layer of complexity imposed by COVID-19 can inform ethically grounded strategies to mitigate it. We see intersecting responses possible at both the level of health care systems and at the level of individual clinicians: identifying workers at high risk based on personal or occupational factors, directing them to care, encouraging positive and culturally relevant coping mechanisms, and reducing, to the extent possible, occupational stressors such as long working hours.
COVID-19 struck the world in the modern age of technology that, for better and for worse, has created a flood of information, an infodemic , and, with it, extensive internet-enabled engagement. The confluence of these forces has enabled people to remain socially connected while physically apart, created both opportunities for intervention as they pertain to the brain and mental health, and raised some new ethical dilemmas as well.
The accelerated transition to online communication and work has profoundly changed the delivery of health care services, now relying on telemedicine not only to reach rural and remote communities as in the past, but for routine care in urban communities alike. In our ethical evaluation of this transition, we place issues of access in the foreground. Both for those who are historically underserved and those who are currently required or encouraged to limit physical contact outside the home, tele-care is clearly better than no care. Telemedicine has its challenges though: the physical examination is limited to words without touch, and evaluations of behavioral health and family dynamics are limited by the availability and capabilities that technology affords to participants who seek to engage [11,12]. Still, for conditions involving mental health, remote assessment has been shown to be effective; for movement disorders requiring detailed neurological examination, less so. Best practices to ensure not only the effectiveness of telemedicine, but also social justice around its use, have yet to be developed.
COVID-19 continues to challenge society economically, socially, and ethically, including through still unfolding effects on the brain and mental health. The pandemic has brought to the foreground debates on timely access and rights to health services. As in many of the 21st century viral epidemics, health disparities have been magnified, particularly in relation to marginalized, rural, and remote communities where comorbidities are prevalent [13,14]. A spectrum of mental health challenges manifest during the course of a viral epidemic; front line workers are not alone in feeling the impact, but the anticipation they face for the care they must provide is a special case for concern. Efforts to establish empirical and authoritative guidance for screen time to ensure safe use, especially among youth, have been trumped. Moreover, even as countries gain a grasp on the near-term impact of COVID-19 on economic recovery, balancing economic reopening with viral suppression efforts when the long-term sequelae, including neurological ones, are very much unknown, is a delicate endeavor. These and many other knowledge gaps require further neuroscience, neuroethics, epidemiologic, social, and cognitive studies (see Outstanding Questions). We hope that this opinion piece offers a useful starting point in the conversation on issues at the intersection of COVID-19 and society that merit that the broadest range of neuroethical attention.
Source: Cell Press